As assisted suicide and euthanasia issues simmer, look at Holland
By MICHAEL J. FARRELL
As a race we have always worked harder at making life good than making death happy. Death unsettles us individually and communally. One manifestation of our nervousness is the expanding debate about assisted suicide and euthanasia.
As the complex and emotional arguments ebb and flow in this country, we would do well to take a look at the Netherlands, "the only country where euthanasia is accepted practice," as Herbert Hendin writes in Seduced by Death: Doctors, Patients and the Dutch Cure (Norton, 256 pages, $27.50).
Hendin, a psychiatrist, has for much of his professional career studied and treated people who wanted to end their lives. In 1990 he became executive director of the American Suicide Foundation, which aims to prevent suicide, assisted suicide and euthanasia. He took over just in time for the currently burgeoning debate fueled by Dr. Jack Kevorkian and others.
While Seduced by Death contains scattered flights of theory, its power to persuade derives from the stark, lived experience in Holland. But also in America, which brings the issues seriously close to home. Such as the story of Tim -- presumably not his real name -- a hard-driving young executive halted by leukemia, with a 25 percent chance of survival. Since Tim, the career track aside, wasn't having much of a life, his insistent pursuit of suicide was in its own way logical.
But if Tim should be allowed legal suicide, should everybody? And if allowing it is good, would insisting on it not be preferable? There is no context on earth in which the term "slippery slope" seems as appropriate as here.
Tim died eventually. But first he took the treatment previously rejected. This allowed him time for unfinished business. "Two days before he died," writes Hendin, "Tim talked about what he would have missed without the opportunity for a loving parting." But for every Tim there is a counter-story in which suicide might seem a good idea. "In the rush to legislate," suggests Hendin, "advocates have failed to understand the problem they are claiming to solve."
Search for answers
The author's own search for a solution took him to Holland in 1993. He learned that even in Holland the legalities are murky. The law still provides punishment for euthanasia and assisted suicide, but the same code stipulates exceptions to the law. By now these "special circumstances" have pretty much become the rule: "In a series of cases over the last 20 years, the Dutch courts have ruled that force majeure is such a special circumstance; euthanasia is thus permitted when a doctor faces an unresolvable conflict between the law, which makes euthanasia illegal, and his responsibility to help a patient whose irremediable suffering makes euthanasia necessary."
A cozy coexistence has evolved between the Dutch courts and the medical authorities who follow agreed guidelines for assisted suicide or euthanasia: (1) voluntariness -- the patient must freely, and repeatedly, ask for it; (2) unbearable suffering -- which cannot be relieved by other means; (3) consultation -- a second opinion.
These guidelines, it turns out, are ideal circumstances for the "slippery slope."
It is hard to be sure how far down the slope the Dutch are, according to Hendin. The best guide is the celebrated Remmelink Report, published in 1991, the work of a government commission headed by Attorney General Jan Remmelink of the Dutch Supreme Court.
The report found assisted suicide uncommon: about 400 cases a year. There were, by contrast, about 2,300 cases of straightforward euthanasia, or about 2 percent of all Dutch deaths. Over 50 percent of Dutch physicians admitted to practicing euthanasia, mostly for cancer patients. Only 60 percent of doctors kept a written record of their cases.
More startling was how quickly physicians had slipped down the slope to involuntary euthanasia, unilaterally terminating the lives of competent patients, as distinct from those who were "out of it." Remmelink reported more than 1,000 cases of death caused or hastened without any request from the patient. In over 5,000 cases, giving pain medication or withdrawing or withholding treatment was done to shorten life.
So-called "demented" patients are in an even more precarious situation. Chairman of the Royal Dutch Medical Association Joost Schudel announced unambiguously, "The doctor decides." Here the doctor's guiding principle should be, according to Schudel: If I were in the patient's position, what would I want for myself? This endearing concept is flimsy ground to build an ethics on. Friends or relatives were not to be given any say in this big decision. Medical Association guidelines also indicated that physicians should not treat demented patients for infectious diseases. The author quotes another Dutch euthanasia advocate: "Pneumonia is an old person's best friend."
Perhaps the most scary aspect is how readily Dutch physicians have grown into the role of God. "There is a certain paternalism built into our system," one conceded. This same doctor railed against the legislation demanding that doctors report all lives terminated without the patient's request -- only those asking for it are entitled to Dutch euthanasia.
This requirement of mental competency for euthanasia is particularly awkward for Alzheimer's patients. At the onset of the disease, patients who decide they don't want to live with it interminably must ask for -- and receive -- euthanasia. They may not ask for it now and get it later when competency deserts them; in this way they are likely to be deprived of months or years of good-quality life.
Dr. Herbert Cohen is one of the best-known practitioners in the Netherlands, with between 50 and 100 deaths to his credit.
"There is a certain satisfaction in being involved in the terminal phase of life," he explained. "There is a special warmth and intimacy and harmony. It is true for them as well; it improves relations among the family. My absolution is the Christmas cards I receive." Sometimes, going to a euthanasia, he has brought flowers.
He is not as cavalier about death as his words might suggest. "The idea that each case gets easier and easier is just rubbish," he tells Hendin. "The price of any dubious act is doubt. ... I don't sleep for a week after." He added that he never drives when about to perform euthanasia, being so focused that he fears an accident.
Most physicians, he said, prefer euthanasia to assisted suicide, which is less tidy. Drugs often take several hours, with relatives phoning, thinking the person is dead. "You have to be present or available on the phone, ready to terminate the life if something goes wrong."
Public opinion in Holland supports assisted suicide and euthanasia, Hendin writes. This includes most lawyers, judges and prosecutors. In a few short years euthanasia has grown to acceptance as a fact of life. Professor Rene Diekstra, one of the fathers of Dutch euthanasia, was nevertheless worried that "there would be a backlash when the public eventually realized what was actually happening. He also thought it possible that world opinion would force the Netherlands to regulate the procedures more carefully."
Case after case bring home to the reader the ambiguity -- at the very least -- that surrounds the issue, and the seemingly ever-steepening slippery slope. Netty Boomsma's was a troubled life. Undesirable parents. Husband who beat her. Her first son, whom she loved best, shot himself after a failed love affair. Her other son died on schedule from an incurable disease.
Netty wanted suicide because she wanted to be with her children. She had no interest in the alternatives, such as bereavement therapy, that the doctors still feel obliged to suggest. Writes Hendin: "Netty needed someone who could tell her in a firm but kind way that she had never really lived for herself and that it was not too late to try. She could always kill herself, but she ought to give life a chance first."
What is ultimately striking about Netty's story, sad though it is, is the extraordinary lengths to which our advanced civilization will go to meet needs that as a race we had to shrug off and walk over since the world began. The world, alas, is and always was full of grief like Netty's, from ancient Egyptian slaves to dead Tutsis in Rwanda, but we seldom could afford the luxury of the options that were afforded Netty. The Dutch system pampered her with advice and offers of assistance before it killed her. Hers was the psychological equivalent of the monumentally expensive tubes and machines that some very old people are hooked up to in hospitals in the wealthy West. It's ironic that death, one way or the other, becomes the culmination of such lavish attention.
The slope gets very slippery. Hendin writes that a major step in normalizing euthanasia as a part of everyday life was the Dutch television showing in the fall of 1994 of "Death on Request." Cees van Wendel, a patient with amyotrophic lateral sclerosis, was put to death on his own request. Part of this program was shown here on "Prime Time Live," where Sam Donaldson described it as "a story of courage and love."
Hendin saw it differently. He writes of the seeming contradiction between the film's message -- that we all want release from illness, especially the patient -- and the obvious eagerness of the patient's wife that he die. She intercepted all questions asked of Cees and answered on his behalf. She appeared "repulsed" by her husband's illness, never touching him during their on-camera conversation.
"From the beginning, the loneliness and isolation of the husband haunt the film," writes Hendin. In this book the old, sick man seems to represent the old and infirm everywhere, getting shouted out of the debate by every side. Alive and human and feeling and no doubt fearing, he is nevertheless depersonalized as if he were already dead. In a culture that has scant care for old age, that voice needs desperately to be heard.
Can of worms
Meanwhile, back in Salem, Oregon, the law allowing assisted suicide has been put on hold following a March 13 appeal by the National Right to Life Committee, according to Catholic News Service. Reservations seem to be growing about the measure, the Oregon Death with Dignity Act, narrowly approved by voters in 1994.
Dr. James Boehnlein, a representative of the Oregon Psychiatric Association, said assisting suicide would make members liable to ethics charges. "None of our training prepares us to decide if a patient is competent to commit suicide," he said. And Dr. Larry Lewman, Oregon's chief medical examiner, has turned from supporter of assisted suicide to opponent: "This is a potentially unworkable can of worms that has been dumped into your laps," he told the Oregon House subcommittee. And Rep. George Eighmey, who supports the measure, said the legislature should make sure that "the right to die never becomes duty to die."
And in New York, Cardinal John O'Connor said in a TV interview that an unspecified insurance company had told the staff of one Catholic hospital, "You are keeping your people alive too long. If you continue to do this, we will cut off your insurance."
Not only are hospitals pressured to shorten life, so are patients, he said. Assisted suicide "sounds wonderful, sounds compassionate," he said, when patients are told about "the fear of suffering" and "what a drain on society they would be [by] taking up another [hospital] bed."
O'Connor said, "We are at the mercy of insurers."
Michael Farrell is NCR's executive editor.
National Catholic Reporter, April 11, 1997